Thanks to enlightened leaders, crusading patient advocates, and the insights of the quality improvement movement, there are a lot fewer Penn States in health care than there used to be. Health care has belatedly recognized that the way to earn public trust is to tell the truth, admit mistakes, apologize, and make things right. It’s the same on the inside. If your employees and staff trust their leaders and each other, they will embrace a culture of disclosure, report near misses, and value errors as learning opportunities. No name, no blame, no shame. Just improve. That’s the deal.

But it’s a hard deal to live up to. There is an irreducible tension between withholding the lash in service of quality improvement and the very human desire to call individuals to account. It sounds Orwellian to be told that your loved one died because of “system error” – even if it’s true. The best-designed systems try to take human variability out of the picture almost entirely. That’s why aviation is so safe and why OR teams that use a surgical checklist outperform the most conscientious teams that don’t.

You shouldn’t have to create protocols for decency, but there’s nothing like the advice of lawyers to scramble the signals of an active conscience. Insurers instructed doctors not to apologize to patients they had harmed because apology implies guilt which creates liability. Patients and their families faced a wall of maddening obfuscation. It took decades to pass legislation – legislation! – that allowed people to say they were sorry. Only a few wise organizations had already understood that telling patients the truth reduced the likelihood of being sued.

I suspect something more elemental explains much of the tragic delay in coming to terms with hard realities. Our moral compass can spin wildly out of control in unfamiliar terrain. The usual defence mechanisms take over: denial of the unthinkable, the instinct to flee, the hope that others will fix it. The longer the silence, the harder it is to come forward because of the added guilt imposed by the rising number of avoidable victims. Finally, inevitably, the evidence overwhelms the protective psychological levee. The reckoning is long, hard, and costly for all involved.

There are moral failings to be sure in these cases, but humans fail morally all the time. More vexing is the failure of curiosity. Why didn’t Paterno want to get to the bottom of the allegations about someone he had trusted for decades? Why didn’t the graduate assistant who told Paterno what he’d seen – now the receivers coach – follow up on what had become of his revelation? And on purely self-interested grounds, how could senior Penn State officials calculate that a cover-up was a sound risk management strategy?

I’d like to think the CEOs of big-time health care organizations would do better than Paterno if faced with a similar situation. And I’d like to think Paterno would have done the right thing had he ventured outside the adulatory bubble to hear from people whose harm was compounded by powerful people who chose to do nothing.

The MASH blog was recently featured on CBC Radio One, with Lewis talking about what health care can learn from sports – specifically from the Moneyball example.

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We Welcome Comments. But please note: We will delete comments that include personal attacks, unfounded allegations, unverified facts, product pitches, profanity or any from anyone who doesn't list what appears to be an actual email address. We will also end any thread of repetitive comments. We don't give medical advice so we won't respond to questions asking for it. Please see more on our comments policy.

I think that Paterno has been the fall guy and the herd reaction against him has been unfair and excessive. I know this view, which I bravely expressed under my own name, is not popular. It’s easy and convenient to look backwards and pontificate how we would have acted differently than someone who’s action or inaction contributed to an unfortunate outcome. http://bit.ly/v3i39O

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December 9, 2011 at 5:14 am

Excellent !

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